Auto Insurance Checkup

First & Last Name ✶

Mailing Address ✶

Location Address (if different)

City State Zip ✶

Phone ✶

Email ✶

Are all vehicles in your household titled to you and your spouse? ✶

Does any resident regularly travel outside the United States? ✶

Are you interested in aftermarket parts for repairs? ✶

Is your vehicle used for any type of delivery? Food, flowers, etc.? ✶

Do any residents rent vehicles for either short-term or long-term use? ✶

Are any vehicles used to plow snow for others? ✶

Are any vehicles used to tow for others? ✶

Are any vehicles used to transport children or others not in your household, other than shared car-pooling arrangements? ✶

Are any vehicles antique or classic cars? ✶

Are you getting all discounts available?

Low Mileage

Deductibles

Good Student

Driver’s Training

Do you own a golf-cart, go-cart, dirt bike, ATV, snowmobile or dune buggy? ✶

Do you often drive vehicles owned by others, including an employer’s vehicle? ✶

Do any of your vehicles have custom equipment? ✶

Are you interested in gap coverage on your auto policy? ✶

Coverage extended for a first time owner of a new vehicle (current year) to provide coverage for difference between the unpaid amount due on the loan and the actual cash value of the vehicle.

Do you need to review your non work life insurance? ✶

Comments

I understand that insurance coverage is not bound or altered until I receive confirmation by an authorized representative of Gallaher Insurance Group ✶

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